For most, diet and exercise—not meds—key path to lower BP

With the release of the new hypertension guideline from a joint task force formed by the American College of Cardiology and the American Heart Association (AHA), physicians and patients have been asking questions about its impact on care. While some associate the growing number of patients defined as having hypertension under the new guideline with increased use of anti-hypertensive medications, the guideline authors said during a panel discussion that the biggest changes will be related to lifestyle factors such as diet and exercise.

To ensure physicians have the information they need to successfully identify, evaluate and manage patients with hypertension, the AMA collaborated with the AHA and TEDMED to host a discussion with two of the lead authors of the new blood pressure (BP) guideline and two experts in cardiology. (An hour-long video is available for viewing; scroll to bottom of page.)

The TEDMED event—broadcast live on Facebook—was moderated by Patricia Salber, MD, a physician executive and serial entrepreneur who has founded and led both for-profit and not for profit organizations. Two of the lead authors of the guideline, Paul Whelton, MD, and Robert Carey, MD, joined the discussion with cardiologists Thomas Lee, MD, and Karol Watson, MD.

Why lifestyle change matters

The new guideline creates an increase, from 32 percent to 46 percent, in the share of U.S. adults who will be diagnosed with hypertension, said Dr. Salber. When looking at the future of hypertension care, she asked the panel how physicians could measure risk and what these new recommendations mean for patients.

“Because of this new classification—what we’re calling stage 1 hypertension—individuals who are in this range are already at double the risk for heart attack or stroke,” said Dr. Whelton, a researcher who has led many of the major National Institutes of Health-funded BP intervention trials and has published more than 400 peer-reviewed manuscripts.

Cardiovascular-risk estimation also is part of the new guideline, which allows physicians to be more careful about who might benefit from BP medication in addition to lifestyle changes, explained Dr. Whelton.

“Although the number of the prevalence of people with hypertension will go up quite dramatically, the number who will require a blood-pressure medication is only going to go up slightly, about 2 percent,” he added.

“What we are trying to do here is to say to everyone that we should reduce the leading causes of hypertension, which are all lifestyle changes,” said Dr. Carey, a renowned clinical endocrinologist and leader in the field of cardiovascular endocrinology. “Lifestyle is the cornerstone and we have several components that we should emphasize. The most important is weight loss and then healthy diet.”

One recommendation he offered was the dietary approaches to stop hypertension (DASH) diet, which is low in saturated fat. The DASH diet will help a patient lose weight and allow them to maintain a healthier diet, Dr. Carey said. He added that salt restriction will be very important lifestyle change, along with increased potassium intake, more exercise and limited alcohol consumption.

“When you get down to it, 90 percent of our problems are due to diet, physical activity and smoking when it comes to cardiovascular disease,” said Dr. Whelton. “Drugs are useful, but they’re not dealing with the underlying problem for most people.”

Dr. Watson, an attending cardiologist and professor of medicine and cardiology at the University of California, Los Angeles David Geffen School of Medicinesaid she likes the guideline’s “totally holistic, integrated approach.” She added that this means the right approach to hypertension management is “not just drugs or lifestyle, it’s everything.”

To address lifestyle changes in patients, Dr. Whelton recommended starting from the beginning because no one becomes a marathon runner overnight. Instead, it begins with a little exercise.

“There are ways to start and we all need to become healthier—we’re protecting our own lives,” he said. “It’s really important to motivate and support patients in their goal to become healthy.”

However, Dr. Watson stated that physicians should “remember there are some structural barriers to a lot of people. They don’t have a mall that’s safe to walk [in] or they can’t afford fruits and vegetables to get the DASH diet.”

“There are real things that are going to require some hard societal discussions about how we get people better care,” she added.

Dr. Carey hopes the guideline will help promote the kind of research needed to clarify the gold standard for behavioral change and believes it can “serve as a can opener for national discussion and research, and hopefully for implementing better methods.”

Team approach to motivating patient change

For Dr. Lee, a practicing internist and cardiologist at Brigham and Women’s Hospital and chief medical officer for Press Ganey, the new guideline prompted him to think about the teamwork that will be needed to face the new challenge.

“The big impact of this report for me is—I didn’t think of medication,” he said. “I thought of my patients and their degree of control. What the guideline is going to do is to highlight the need for my colleagues and I to work together to control hypertension.”

“We have moved up the number who are aware, the number being treated and the number being controlled,” said Dr. Whelton. “As we become more aware, team-based approaches in which patients play a role are very important.”

For example, physicians seeing patients in the office have a time deadline and may not have the time to complete everything required or recommended in the guideline. This is where team-based care is needed.

“Team-based care involving nurses, nurse practitioners, social workers, physician assistants, pharmacists and others are going to be extremely important,” Dr. Carey said. “We can partner with members of the team to deliver balanced holistic care to these patients. Then we can take advantage of the lifestyle list.”

“In the past we have often overlooked it because, frankly, as physicians we did not have the time to do it,” he added.

At the end of the day, it’s all about empowering, supporting and helping the patient, said Dr. Whelton. However, the patient needs to change their behaviors, which isn’t easy. He urged physicians to support the patient to make a difference.

“At minimum, there are two members of the team—there’s the clinician and the patient,” he added. “Start with two and expand that. Are there other people who can come in to help?”

The Million Hearts Hypertension Control Challenge is a federal competition to identify clinicians, practices and health systems that have achieved a hypertension control rate of 70 percent or greater among their patients with hypertension and award them with recognition for their work. Learn about the 2017 Hypertension Control Champions.

Target: BP™ is a national initiative co-led by the American Heart Association and the AMA. In addition to direct access to trained field support specialists, a data platform and a suite of evidenced-based tools and resources offered by the AMA and the AHA, Target: BP offers annual, recurring recognition for all participating sites that achieve hypertension control rates of 70 percent or higher among their adult patient population year over year. Learn about the 300-plus organizations recognized by Target: BP.